Psychopathology, Leonhard’s classification and the deconstruction of Kraepelin’s manic-depressive psychosis

Thomas A. Ban

In the 8th and last edition of his Textbook, in which the chapter on manic-depressive psychosis was written by himself, Kraepelin (1913) defined manic-depressive psychosis (MDP) in terms of “etiology” as an endogenous psychosis “whose appearance is generally unrelated to external circumstances”. He described it in terms of “symptomatology” as an illness that becomes manifest in one of three states/forms: (1) “manic states” characterized by heightened mood, flight of ideas and increased drive; (2) “depressive states” characterized by sad or anxious mood, thought retardation and decreased drive; and (3) “mixed forms” in which ”signs of mania and depression appear simultaneously, so that pictures ensue whose traits correspond to those of both illnesses and yet they cannot be classified to either one”. And he characterized it in terms of “course” as an episodic, remitting and relapsing illness, which “as a rule consists of separate attacks more or less sharply delimited from each other or from the normal state of health” (Berner et al 1983).

By stipulating these criteria, Kraepelin (1913) united the “entire realm of periodic and circular insanity, uncomplicated mania, the majority of illness entities taken from ‘melancholia’, and also a non-negligible quantity of amentia cases, including certain mild and moderate mood modifications, which on the one hand are to be considered as preliminary stages of more severe disorders, on the other as blending into the realm of individual nature”. He argued for bringing all these varied conditions together under the diagnosis of MDP by pointing out that despite the differences in the clinical picture, “some basic traits in all these illnesses recur”, that the various illness forms merge into each other without recognizable boundaries, supersede each other in the same patient, have a uniform prognosis and “can replace one another in genetic ascendency” (Berner et al. 1983).

In contrast to Kraepelin (1913), Leonhard (1957, 1986) offers only minimal guidance for diagnosing the 16 forms (including 10 sub-forms) of illnesses that resulted from his deconstruction of Kraepelin’s MDP. His monograph on The Classification of Endogenous Psychoses has remained from the 1st to the 6th and last edition published in his life time a collection of case reports with little introductory and summarizing texts characterizing the different forms and sub-forms of these illnesses. Yet, Leonhard argues (1957) that within the “phasic psychoses” already in the first phase (episode) of the illness, “bipolar” manic-depressive disease can be separated from “unipolar” pure mania and pure melancholia, as well as from the “unipolar” pure depressions and “unipolar” pure euphorias. He contends that the signal difference between “bipolar” manic depressive disease and the “unipolar” forms of “phasic psychoses” is that the “bipolar” form displays a more colorful appearance by varying not only between two poles, but by displaying in each phase and even during a phase different clinical pictures to the extent that no clear syndrome can be described. In contrast, the “unipolar” forms return in a periodic course with the same symptomatology with every individual “unipolar” form characterized by a syndrome associated with no other form and not even related transitionally to any other forms. As the differentiation is not based on the presence or absence of a specific psychopathological symptom or a set of psychopathological symptoms in a point of time, but on the entire (“holistic”) clinical picture in permanent flux, arguably it would be more proper to refer to “monomorphous” and “polymorphous” phasic psychoses then to “unipolar” and “bipolar” phasic psychoses (Petho 1990).

Within Leonhard’s frame of reference, pure mania/pure melancholia can be differentiated from the pure euphorias/pure depressions on the basis of their psychopathology, as pure euphorias/pure depressions are exclusively affective diseases, whereas in pure mania/pure melancholia thought and desire are also disturbed. Thus, in pure melancholia and pure mania all three cardinal symptoms of the melancholic syndrome, i.e., depressed mood, psychomotor retardation and thought retardation, or of the manic syndrome, i.e., elated mood, accelerated thinking and increased psychomotor activity are obligatorily present, whereas in the “pure depressions” and “pure euphorias” thought and desire are not necessarily affected.

In so far as “bipolar” phasic and cycloid psychoses are concerned, Leonhard’s (1957) differentiation is based exclusively on the dominant “elementary” symptom pair, i.e., depressed or elated mood, in case of manic-depressive illness; anxious mood or ecstasy in case of anxiety-happiness psychosis; excited or inhibited confusion in case of excited-inhibited confusion psychosis; and hyperkinesia or akinesia in case of hyperkinetic-akinetic motility psychosis.

The first diagnostic algorithm that provided diagnoses in Leonhard’s classification, relevant to Kraepelin’s MDP was the KDK Budapest, developed by Petho, Ban, Kelemen, Karczag, Ungvari, Bitter and Tolna. It was published in 1984, in the Hungarian periodical, Ideggyogyaszati Szemle. The second diagnostic algorithm was its English adaptation, the DCR Budapest-Nashville, developed in the mid-1980’s by Petho and Ban in collaboration with Kelemen, Ungvari, Karczag, Bitter, Tolna (Budapest), Jarema, Ferrero, Aguglia, Zuria and Fjetland (Nashville); and the third, the Schedule for Operationalized Diagnosis for the Leonhard Classification (SODLC), developed in the late 1980’s by Fritze and Lanzig. Both, the DCR and the SODLC were published in Psychopathology, in 1997 and in 1990, respectively.